Assessment of atraumatic knee conditions in children

Specialty: Children's Orthopaedic
Age group: Children

Criteria for referral to public hospital service

• Severe or progressive knee pain that has persisted for longer than 3 months with functional impairment or sleep disturbance that has been unresponsive to medical management
• Osteochondritis dissecans (OCD) of the knee
• Osgood-Schlatter disease with symptoms that have persisted for longer than 18 months that are unresponsive to medical management
• Spontaneous osteonecrosis of the knee
• Bow legs in a child older than 3 years with progressive or excessive deformity that
  • are asymmetrical
  • are painful or occur after a traumatic event
  • have an intercondylar separation greater than 6 centimetres or
  • associated with other skeletal deformity such as height below fifth centile for age
• Persistent knock knees in a child older than 8 years with progressive deformity that
  • are asymmetrical
  • are painful or occur after a traumatic event
  • have an intermalleolar separation greater than 8 centimetres or
  • is associated with other skeletal deformity such as height below fifth centile for age.

Information to be included in the referral

Information that must be provided

• Reason for referral and expectation or outcome, anticipated by the child, or their carer, and the referring clinician from referral to the health service
• Findings on physical examination
• The functional or psychological impact on quality of life or activities of daily living including impact on work, study, social activities or carer role
• Pain history: onset, location, nature of pain and duration
• Details of previous management and pain management including the course of treatment(s) and outcome of treatment(s)
• Child’s age
• Relevant medical history and comorbidities
• For bow legs intercondylar separation when standing with feet together (single or serial measurements)
• For knock knees intermalleolar separation when standing with feet together (single or serial measurements)
• If referral relates to injury detail: date, mechanism, severity, recurrence and evolution of injury
• X-ray of two views of the affected knee: weight bearing anteroposterior (AP) and lateral (including details of the diagnostic imaging practice)
• If referral relates to infection or inflammation provide full blood examination and inflammatory marker results (erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)).

Provide if available

• Details of any previous joint surgery including when and where procedures were performed
• MRI scan where there is ligament damage (including details of the diagnostic imaging practice)
• Statement about the parent(s) or guardian’s interest in having surgical treatment if that is a possible intervention
• If the child is neurodiverse, gender diverse or has a disability
• If the child identifies as an Aboriginal and/or Torres Strait Islander
• If the child has a preferred language other than English and if they rely on cultural or linguistic support (e.g. Aboriginal cultural support, an interpreter)
• If the child lives in out-of-home care (foster care, kinship care, permanent care or residential care)
• If the child is aged 14 to 18 years, do they consent that their health information is shared with their parent, guardian or carer.

Additional comments

The Minimum information for referrals to non-admitted specialist services lists the information that should be included in a referral request.

Ultrasound imaging is not indicated.

The referral should note if the request is for a second or subsequent opinion as requests for a second opinion will usually not be accepted.

Where appropriate and available the referral may be directed to an alternative specialist clinic or service.

Referral to a public hospital is not appropriate for

• Osgood-Schlatter disease or Sinding-Larsen-Johansson syndrome where the symptoms have responded to medical management
• Recurrent patellar dislocation where non-surgical treatment modalities have not been trialled
• Physiological bow legs that have resolved
• Physiological knocked knees that have resolved.